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Anesthesia and Liver Disease

Anesthesia and Liver Disease . E.A. Steele, MD May 4, 2005. Liver Anatomy. Liver Anatomy cont. Liver Blood Flow. Portal Vein 70% of total flow 50% of oxygen (only has 85% sat) Dependent upon flow thru GI tract Hepatic Artery 30% of total flow 50% of oxygen

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Anesthesia and Liver Disease

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  1. Anesthesia and Liver Disease E.A. Steele, MD May 4, 2005

  2. Liver Anatomy

  3. Liver Anatomy cont.

  4. Liver Blood Flow • Portal Vein 70% of total flow 50% of oxygen (only has 85% sat) Dependent upon flow thru GI tract • Hepatic Artery 30% of total flow 50% of oxygen autoregulated to meet liver demand

  5. Metabolic functions • Carbohydrate metabolism – glycogen storage • Fat metabolism – fatty acids • Protein metabolism – protein deamination to urea, amino acid conversions, plasma protein production • Drug metabolism • Other - T4 to T3, vitamin storage

  6. Protein Metabolism • Deamination – converts a.a. into carbohydrates/fats with ammonia as by-product. Ammonia is toxic • 2(Ammonia) + CO2 = urea • Plasma proteins • Albumin, coagulation factors (exc. Factor 8 and vWF), plasma cholinesterases, transport proteins

  7. Bile • Bile ducts become R & L Hepatic Ducts become hepatic duct, joined by the cystic duct to form the common bile duct to the sphincter of oddi along with the pancreatic duct • Bile acids for cholesterol elimination and fat absorption (fat soluble vitamins) • Bilirubin exrection • heme – RES – Bilirubin in blood (unconjugated) – liver (conjugated) – excreted in bile mostly, small amt abs in blood or converted in intestines to urobilinogen

  8. Evaluation of liver function • Large functional reserve of liver, hence there may be significant liver damage before abn. Laboratory tests. • AST/ALT • Bilirubin • Alk Phos • Albumin • Ammonia • Coags

  9. Aminotransferases • Aspartate aminotransferase (AST=SGOT) • Alanine aminotransferase (ALT=SGPT) • Alpocanine aminotransferase (APT=SPOT) Released from liver cells as they die Normal levels below 40ish. Alcohol ALT<AST

  10. Bilirubin • Unconjugated • Hemolysis, congenital defects of conjugation • Conjugated • Hepatocellular dysfunction, obstruction • kernicterus • Total

  11. Albumin • Low levels • Decreased production • Liver disease, malnutrition, stress • Increased loss • Renal, gut

  12. Coagulation • Protime/INR • Fibrinogen, Factors V, VII and X, prothrombin • Factor VII has a half-life of 5h, with acute liver injury can see prolongation of PT quickly • What’s the point of giving FFP the night before surgery? Very little. • FFP given just before surgery • Vitamin K 12-24h before surgery

  13. Effect of Anesthesia on the Liver • Hepatic blood flow • Decreased portal vein flow • Decreased hepatic artery flow (decrease C.O., Decreased MAP) • Ventilation (PPV, PEEP) • Surgical procedure

  14. Anesthetic effects (cont) • Biliary function • Sphincter of Oddi spasm • Glucagon • Halothane hepatitis • Degree of metabolism • Pt. at risk: Female, fat, forty, repeat exposure

  15. Post-op jaundice Most likely due to pre-operative dysfunction Drugs (incl OTC and herbals), sepsis, exogenous bilirubin load (old blood), occult hematomas, hemolysis, perioperative events (hypotension, hypoxia), co-morbidities (CHF), Remote possibilities: “Benign postoperative intrahepatic cholestasis” assoc. with long surgery complicated by hypotension, hypoxemia, massive transfusion; immune-mediated hepatoxicity

  16. Cirrhosis • Affects all organ systems • Surgical risk related to degree of hepatic impairment all other things being equal (emergency surgery, type of surgery, comorbidities)

  17. Child-Pugh (or Child-Turcotte)score • Assigns points (1, 2 or 3) for stigmata of cirrhosis Ascites, bilirubin, albumin, PT/INR, Encephalopathy Basically, the healthier you are the lower the score. A low score is Grade A – well compensated disease with a 1-2 year patient survival of 85-100%. Grade C, decompensated disease, 1-2 year survival at 35-45%. This corresponds to perioperative mortality rates of 10, 31 and 76% for increasing Grades. MELD scores are prob. Similar to Child-Pugh in predicting mortality. Model for end stage liver disease score.

  18. Surgical/Invasive Procedures • ERCP • TIPPS • Cholecystecomy • Hepatic resection • Liver transplant

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